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Client Intake Form

This document is a client intake form for Premier Business Solutions, collecting personal and financial information from taxpayers and their spouses. It includes sections for direct deposit information and a checklist of required income and expense data for tax return preparation. The form also asks about dependents and how the client was referred to the service.

Uploaded by

Frances Athena Baraoidan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
24 views

Client Intake Form

This document is a client intake form for Premier Business Solutions, collecting personal and financial information from taxpayers and their spouses. It includes sections for direct deposit information and a checklist of required income and expense data for tax return preparation. The form also asks about dependents and how the client was referred to the service.

Uploaded by

Frances Athena Baraoidan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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1403 Greenbrier Parkway,

Suite 220
Chesapeake, VA 23320

Client Intake
Date & Time Received:

Taxpayer Name
Occupation
SSN Birthdate _
Driver’s License # Date Issued Expiration
Taxpayer Phone
E-Mail
Address

Spouse Name
Occupation
SSN Birthdate
Driver’s License # Date Issued Expiration
Spouse Phone
E-Mail
Are you a new client? YES NO
How were you referred to Premier Business Solutions?

Months Lived
Dependents Name Birthdate Social Security # Relationship to You
in Your Home
List Youngest First)
If you would rather your tax return direct deposited instead of a check sent in the mail please fill out the
information below.

Direct Deposit Information

Name of Bank:
Routing Number:
Account Number:
Tax Return Checklist
o Personal information -
 Last year’s income tax if you are a new client.
 Banking information if Direct Deposit Required

o Income Data Required -


 Wages and/or Unemployment
 Interest and/or Dividend Income
 State/Local income tax refunded
 Social Assistance Income
 Pension/Annuity/Stock or Bond Sales
 Contract/Partnership/Trust/Estate Income
 Gambling/Lottery Winnings and Losses/Prizes/Bonus
 Alimony Income
 Rental Income
 Self-Employment/Tips
 Foreign Income

o Expense Data Required -


 Dependent Care Costs
 Education/Tuition Costs/Materials Purchased
 Medical/Dental
 Mortgage/Home Equity Loan Interest/Mortgage Insurance
 Employment Related Expenses
 Gambling/Lottery Expenses
 Tax Return Preparation Expenses
 Investment Expenses
 Real Estate Taxes
 Estimated Tax Payments to Federal and State Government and Dates
Paid
 Home Property Taxes
 Charitable Contributions Cash/Non-Cash
 Purchase qualifying for Residential Energy Credit
 IRA Contributions/Retirement Contributions
 Home Purchase/Moving Expenses

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